Articles
Dr Jo Coldron, GP Partner at Tavyside Heath Centre
Anxiety is something that effects all of us at some time. For some it may be limited to the time of an exam or a wedding day but for others it can be a much more pervasive feeling impacting how they feel weekly, daily or even hourly.
I have many discussions with my patients about lifestyle choices and how they can reduce anxiety. Many of these are more challenging to implement at present and may need to be adapted but can still be powerful changes we can make to help ourselves.
Exercise – exercise outside is hugely beneficial, but if you aren’t able to do this exercise inside such as Joe Wicks, yoga or chair exercise can still help. Find something you enjoy and doesn’t feel like a chore to get the most benefit.
Diet and alcohol – despite the on-going stressors trying to maintain control over alcohol intake and keeping to a healthy diet is hugely important for our mental health.
Sleep – try and keep to a routine with good sleep hygiene despite the current changes to our work and social lives.
Social support – this has been most impacted in the last few weeks. We can no longer meet our friends, attend our clubs, see our families and we have all felt the hardship of this. It’s so important that we get this social contact in any way we can at present – talking over the garden fence, video calls with our friends and family, attending groups and religious services online, messaging groups….whatever works for you.
Purpose and activity – many people who had busy jobs and lives have suddenly found themselves adrift with nothing they have to do. Find some purpose – perhaps helping a neighbour, decorating the spare room, writing a novel or learning a language. A busy mind and body is a useful tool in the fight against anxiety with altruistic and charitable actions bringing even more positive benefits.
If despite doing all you can with these practical measures anxiety is still a major issue there are techniques that can help:
Identify when you feel anxious. What increases your feelings of anxiety and what decreases them? A diary can sometimes help with this. For example does reading the news increase your anxiety? Does doing some knitting calm your mind? Try and minimise exposure to those activities that make you feel worse.
Try to recognise anxiety inducing thoughts, challenge those thoughts and try and replace them with more positive constructive ones. Practice recognising when thoughts are making you feel anxious and try and catch them early. To help challenge them imagine what you would say to a friend to help them feel better. Often we find ourselves concentrating on the negatives of a situation rather than the positives – try and change this negative into a positive. For example instead of thinking ‘I am going to do this exam and I’m going to fail’, try and think about how well prepared you are, that you really know your stuff, that you’ve done really well in practice exams, and you are going to do your best. It’s important to know that this attempt to change negative thoughts into positive ones won’t always work, but with practice it can become easier. Think of it like going to the gym. Every time you work those mental muscles they get a little stronger and it takes less effort to use them.
If you find repetitive intrusive anxious thoughts are overwhelming you for much of the day you can’t simply turn these thoughts off, they need listening to and addressing. Try and make a specific time in the day to do this and aim to think about them in a structured and productive way. During the day you can put the worries to one side by using various techniques. Perhaps write them down to think about later, use distraction techniques, calming activities or practice mindfulness. When you do allow time to address your anxieties use techniques to make this time positive rather than negative. Perhaps use a worry tree to face the problem, reframe thoughts and come up with practical solutions.
Lots of support is available online to help you manage your anxiety and develop these techniques. A good starting point with lots of helpful links is:
https://www.nhs.uk/oneyou/every-mind-matters/anxiety/
If you feel you need some more help to manage your anxiety you can self-refer to our local NHS depression and anxiety service called Talkworks at the following address:
Asthma is one of those medical topics that we all know something about. All of us would at the very least know someone with it, many of you reading this will be a member of a whole family of asthmatics. However it’s a condition, perhaps because of it’s familiarity, that is historically undertreated and therefore causes far more morbidity, and claims far more lives, than it should.
Asthma can present at ANY age, although it’s often thought of as developing only in childhood. If presenting in early childhood it can then sometimes disappear or regress for many years, but if diagnosed in adulthood, the condition tends to remain. Asthma typically presents with shortness of breath, wheeze, cough and a feeling of a tight chest or restriction to breathing. The symptoms of asthma are caused by inflammation in airways, which can be made worse by inhaled allergens and infections. However the diagnosis can sometimes be challenging because there is an overlap in symptoms with other conditions such as viral induced wheeze in children and acid reflux, bronchitis and emphysema, and lung cancer in older adults.
The diagnosis of asthma is confirmed together by the GP and practice nurse and can include the following steps:
History – What are the symptoms? Does anything trigger them? Is there a family history? Does the patient have eczema or hay fever?
Tests – A peak flow diary and spirometry are commonly used tools in general practice. Tests to rule out other things may be considered, for example a chest x-ray.
Trial of treatment – Sometimes a trial of inhalers can confirm the diagnosis – especially in the very young who can’t complete any of the other tests.
There’s currently no cure for asthma, but treatment can help control the symptoms so patients are able to live a normal, active life.
Inhaled therapy –
Reliever inhalers: Most asthmatics will have one of these but although very important they are not the main stay of symptom management most of time except in the very mildest asthma. If you are using your blue inhaler more than 3 times per week on a regular basis you should be seeing the asthma nurse to discuss whether it’s possible to improve your prevention treatment.
Preventer inhalers: Are used every day to decrease inflammation in the airways and reduce sensitivity and reactivity of the lungs. These are either just a steroid medicine or a combination of a steroid and a long lasting version of the reliever inhaler.
Tablets – Some tablets are taken every day as a preventer. Some, such as steroids and antibiotics tend to be used as ‘rescue medicines’ for exacerbations.
Daily symptoms of cough, shortness of breath and tiredness are impactful and we certainly want to reduce those, but the main threat of asthma is the abrupt and rapid deterioration of an asthma attack which in it’s worst form can be life threatening.
The frequency of asthma attacks, and therefore the danger of asthma, can be reduced by the following actions:
Being on the right level of treatment – both being prescribed it and using it regularly.
Having an asthma plan: An asthma plan helps the asthma patient identify a significant deterioration in symptoms and (most importantly) know what to do about it – whether that’s increasing inhalers, starting a ‘recue pack’ of steroids or contacting the medical services. Patients who are adept at monitoring and assessing their symptoms can more quickly and appropriately respond to them, reducing the chance of deterioration into an out of control and life threatening situation. For younger asthma patients and asthma plan is a good way of communicating information to any of those involved in their care – family members, teachers, family friends etc.
It’s important that if you have asthma and don’t have a personal action plan you make an appointment with your practice’s asthma nurse to discuss one. If you do have one, and even if your symptoms are well controlled, you should have an annual review with the asthma nurse to discuss your symptoms, current treatment and review your plan. There is a huge amount of research in the field of asthma and you should always be up to date with the best treatment.
More information on the presentation, diagnosis and treatment of asthma is available at:
https://www.asthma.org.uk
https://www.nhs.uk/conditions/asthma
Guest writer- Dr Emily Hallahan, GP at Tavyside Health Centre
I had been training as a medical student, junior doctor and then GP in the NHS for over 10 years when I had my first child. During this time I had received no significant formal training or education on the topic of breastfeeding, and had only limited awareness of its health benefits and the problems that can arise. Thankfully I was very fortunate to have a smooth journey with breastfeeding personally and it had a very important, positive impact on my family. However I was increasingly aware that this was not the case for everybody. I therefore decided to train as a peer supporter so that I could encourage, help and support more families with breastfeeding. This training opened my eyes to just how important breastfeeding is and how we all need to support and encourage it as best as we can.
Benefits of breastfeeding
The benefits of breastfeeding are plentiful. It’s free, natural, environmentally friendly, easily accessible and nutritionally complete. It is also effective as comfort, pain relief and an easy sleep aid. Breastmilk has properties that help establish a healthy gut biome, a strong immune system and reduces the risk of common childhood illnesses and conditions such as asthma or eczema. It also has been shown to lower the risk of Sudden Infant Death Syndrome. Adults who were breastfed as children have lower rates of obesity, diabetes and cardiovascular disease so the benefits are often lifelong.
Breastfeeding however is not only about the benefits to the child as the benefits to the mother are also significant. There is strong evidence that breastfeeding reduces risk of breast cancer, ovarian cancer, heart disease and obesity lifelong. Breastfeeding releases a hormone (oxytocin) which helps mothers to feel calm and bond with their child and lowers the risk of post natal depression.
Unicef UK predicts that increasing breastfeeding rates could save the NHS up to £50 million each year.
The Reality
Despite all of these benefits there are some quite surprising UK statistics on breastfeeding rates. The most up to date UK figures from 2010 report that over 81% of babies were initially breastfed. However at six weeks exclusive breastfeeding had dropped to 24% in England and then to only 1% at six months. This is in contrast to the World Health Organisation’s recommendation for breastfeeding to continue until at least 2 years of age due to the continued benefits. We know that breastfeeding beyond infancy is the biological normal and the benefits of human milk are not time limited.
There are lots of reasons that breastfeeding often ends earlier in our culture and every mother will have their own personal reasons for when and why their journey ended, and of course any duration or form of breastfeeding should be celebrated. However breastfeeding can also be a very traumatic and grief ridden subject. It is important to acknowledge that for a small number of families breastfeeding is not possible even with all the right medical and social support in place. Examples include mothers and babies with certain medical needs or some adoptive families. For most families however breastfeeding is achievable but may require some external support. It is crucial that help is available when a breastfeeding journey is at risk of ending prematurely because of issues such as pain, uncertainty, growth concerns, misinformation or just a general lack of support.
This is where peer support groups are so important. It is now recognised in the National Institute for Health and Care Excellence (NICE) guidance that peer support is a key part of managing and supporting feeding difficulties. Peer supporters are volunteers who have completed training on common feeding issues and also have their own experience of breastfeeding. Occasionally further specialised support is needed but more often than not issues can be resolved with peer support.
Mama to Mama
We are very fortunate to have a thriving peer support group in Tavistock. ‘Mama to Mama’ has been running for just over 1 year. In this time the 8 peer supporters have welcomed over 70 mothers. Some mothers attend with feeding issues and some just for the social community. We welcome breastfeeding, combi-feeding and expressing and we also love to see expectant mothers joining us. The group has a real ‘village’ feel with an active WhatsApp group for sharing useful resources, organising social events and offering a listening ear during those tough parts of parenting.
Mama to Mama Breastfeeding Support runs 10:00-11:30 every Friday at 76 on West Street, Tavistock. Drop-in and free to attend. Siblings welcome. Find us on Facebook: www.facebook.com/TavistockBreastfeedingSupport.
References:
https://www.unicef.org.uk/babyfriendly/about/breastfeeding-in-the-uk/
https://www.nice.org.uk/guidance/qs37/chapter/Quality-statement-4-Face-to-face-feeding-support
Dr Jo Coldron, GP Partner, Tavyside Health Centre
Falls are a much more common occurrence than any of us might think affecting one-third of people over 65 living in their own homes each year. Yet falls should NOT be seen as a normal part of aging, to be accepted as inevitable and ignored if possible. We can all fall, at any age, but as we get older we naturally get closer to the ‘fall threshold’, however it always takes something else happening to us to push us over that threshold. So, in the event of a fall we should be focussing not on the age of the person but on the thing that happened – on this day, to this person – that made them fall. The reasons for falls are varied. Some are serious, for example arrhythmias of the heart. Some are acts of god, for example a tearaway poodle or a freak gust of wind. Whatever the events a fall should always prompt examination of the reasons, and an attempt made to reduce the chance of being pushed over that threshold again by something similar.
Falls in the older population have the potential to have much more impact than if a younger person trips over the runaway poodle. Greater rates of osteoporosis (thin bones) means fractures are more likely and arthritis and weaker muscles mean ‘saving’ mechanisms are less effective. Half of older people who fall are unable to get back up without assistance and being stranded on the floor for some time can lead to significant injury. An important consequence, and one not as immediately obvious perhaps as broken bones and cuts, is a loss of confidence. Overnight a person’s world can suddenly shrink with all that hard won independence of a lifetime destroyed. Pavements and steps become something to be avoided and shopping trips out alone now seemingly impossible.
If you or a relative has a fall the reasons for that fall should be assessed as these events could be a warning sign of underlying illness. Clearly if significant injury has occurred this will be in the emergency department, but even if recovery is swift and no immediate help is required a routine appointment with your GP to discuss the events of the fall could be useful. Your GP will try to establish the balance of causes. Was it something medical like reduced sensation due to diabetes or poor eyesight causing a tip over a carpet edge? Was it something in the environment like steep steps into the house that should have grab rails fitted or poor lighting in a hallway? Or was it an event like taking 2 blood pressure tablets that morning by mistake? Often discussing events, a basic examination and medication review is all that is required. Sometimes further tests can help for example blood tests or an ECG (tracing of the heart), and occasionally referral to specialist services is required.
As GPs we normally see people after a fall. Much better than assessing and treating falls after they’ve happened would be the prevention of falls in the first place. This can and should be done of course as we get older, but we should all be thinking about this while we are still young-ish.
Here are some prevention ideas that we know can reduce the risk of falls:
- Regular medication reviews – many medicines such as sleeping tablets greatly increase the risk of falling, especially as we get older.
- Regular vision checks and wearing the correct glasses.
- Thinking about simple things such as choosing well-fitting slippers or putting the light on when going to the loo at night.
- Fall proofing your home for example getting the lighting right, removing trip hazards and installing grab rails.
- Keeping joints, bones and muscles strong with a good diet and plenty of regular physical activity.
- Improving balance with yoga and T’ai chi or specialised balance fitness classes.
If you are getting older or you have an elderly relative there are some great resources about how to prevent falls at the following sites:
A huge thanks to Amanda who gave me the idea for this article. She works for the falls clinic and is passionate about her work but would happily put herself out of a job by getting everyone to do T’ai chi and thus prevent all falls.
Dr Jo Coldron, GP Partner at Tavyside Health Centre
When I was training in general medicine as a student and then a junior doctor we were taught that viral Hepatitis C (HCV), for most people I would diagnose with it, would be incurable. For most people (70%) when they first catch Hepatitis C they don’t have any symptoms, but around 80% would go on to have chronic Hepatitis C which in most of them very gradually cause damage to the liver so you could be living with the disease for many years and not even know. When it did start causing significant damage to the liver there was then little we had to offer in terms of therapy to treat the virus. For some people Hepatitis C causes severe disease, liver cirrhosis and even liver cancer. But there has been an incredible breakthrough in availability of new treatments in the last decade and the World Health Organisation has made it a goal to eliminate Hepatitis C by 2030, this is huge given that around 71 million people are living with chronic Hepatitis C infection worldwide.
In the UK, it is estimated that approximately 160,000 people are living with hepatitis C, although many remain unaware of their condition. Historically, hepatitis C treatment was difficult, lengthy, and involved painful regimens that could include weekly injections and side effects like fatigue and flu-like symptoms. This made it difficult for many people to adhere to treatment, contributing to ongoing transmission and progression of the disease. The new medications which are direct-acting antivirals (DDA) are very effective, the courses are short (8-12 weeks) and they have minimal side effects so almost everyone can take them and achieve a cure (>95%).
So now that we have an effective and well tolerated treatment for Hepatitis C which we can refer patients for, the key is identifying those who should have treatment. Some may be people that already know they are Hepatitis C positive but just couldn’t tolerate previous treatments. Some may be people who do not yet know they are infected.
Hepatitis C is spread by blood products or close contact with someone else who is infected. Any of us could have Hepatitis C infection and if we see abnormal liver function tests we often check for infection, but there are some groups of people that are more at risk of exposure and we should be offering testing for anyone with risk factors BEFORE there’s any evidence of liver inflammation or damage. These are the following suggested groups:
- Close family contact of Hepatitis C positive person, or babies born to Hepatitis C positive mother.
- Anyone who’s ever injected drugs, including gym drugs.
- People with alcohol dependence.
- Men who have sex with men.
- Anyone involved in sex work.
- People born in a country with medium or high prevalence of HCV.
- Anyone who’s been in prison or young offenders institution.
- Homeless people or looked after children or those in children’s homes.
- Anyone with HIV, or haemophilia or people who received blood or blood products before 1991.
- Anyone who got a piercing, tattoo, acupuncture or cosmetic surgery abroad or in unsterile conditions.
If you feel you should have a Hepatitis C test please consider discussing it further with your GP Surgery. GPs are not the only groups leading the charge to identify and eradicate Hepatitis C. Tests are being offered in prisons, drug and alcohol services, Emergency departments, antenatal clinics and pharmacies. To widen the net further anyone in England can request a free, self-sampled finger-prick bloodspot test kit for hep C to use at home and return by post. Order online at hepctest.nhs.uk. People with a negative result are informed via text, and those with a positive result are linked directly to their local viral hepatitis team.
These are great websites with lots of information for everyone from any background, and links to order free test kits:
The Hepatitis C Trust | Hep C charity
Dr Jo Coldron, GP Partner at Tavyside Health Centre
I have just come back from Indonesia and as is common in many countries I saw people resting, working and eating in a deep squat position. I used to think that squatting, which clearly improved hip, knee and ankle mobility and core strength, must be the reason for the lower rates of lower limb osteoarthritis in Asia and Africa compared to Europe but it seems research doesn’t back this up and in fact prolonged deep squatting can be a risk factor for hip osteoarthritis. So what can decrease our risk of hip arthritis?
The key things are:
- Decrease stress and injury to the joints
- Move the joints
- Stabilise the joints
Decrease stress and injury to the joints
Sport and injury – we previously called osteoarthritis ‘wear and tear’ arthritis giving the impression that all the steps we take gradually wears the joint away. While it’s true that elite sports that put a lot of pressure on the joints or cause injuries are linked to increased osteoarthritis, normal recreational participation, if you don’t sustain injuries, is protective and people have less osteoarthritis symptoms if they continue to run, play tennis or golf, cycle or swim so keep doing these as long as you can.
Weight – higher weights are linked to more osteoarthritis and losing weight if you have osteoarthritis can help significantly with symptoms.
Other medical conditions can influence osteoarthritis development such as reduced bone density (osteoporosis) and diabetes, so eating and exercising to improve general metabolic health can decrease the risk of osteoarthritis.
Move the joints
Any position whether sitting, standing or squatting, is detrimental to joint health if done for long periods and movement is beneficial. Changing position regularly prevents one area of the joint taking all the load or strain and potentially sustaining damage but perhaps more importantly regular movement increases the lubrication of the joints and nutrient replenishment so the joints feel less stiff and painful and recover better from small injuries.
In our modern lives we are often put in positions where we sit in one position for long hours: At the office, in the car or at home watching TV. There are some relatively simple things we can do to reduce the impact of this. Take ‘movement snacks’ throughout the day – regularly get up from the chair and walk for a few minutes, consider adding in some exercises that move the body a little more like squats, lunges, forward bends or standing rotations.
Standing desks are popular now and are certainly a positive move but don’t feel you have to stand all day – moving between standing and sitting is good, and even if using a standing desk you still need movement breaks or changes in position to be kind to your joints.
Consider, if possible for you, sometimes sitting on the floor rather than on a chair or sofa. It improves core strength, gets your hips and knees into positions they don’t usually experience when in a chair and you naturally regularly change position on the floor to keep comfortable.
Stabilise the joints
The joints are protected and allowed to function effectively by the muscles around them being strong and balanced. Our bodies are very economical and if we don’t use something regularly the body stops maintaining it. Activity and strengthening exercises are important to maintain muscle strength but this doesn’t have to mean joining a gym or an exercise class if this isn’t the right thing for you. Walking is the absolute best thing you can do for your body. 10,000 steps is the goal but the most benefits happen when you increase from lower numbers eg from 500 to 2000 steps per day rather than 8500-10000.
Consider whether you can add these 2 changes in:
Standing on one leg. Start small – hold on to something and just raise one leg an inch for a few seconds. As you gradually get stronger increase the time and even increase the challenge by closing your eyes and holding your arms up. Not only does this exercises increase leg muscle strength it also improves balance and reduces the risk of falls.
I used to think that the greatest health benefit of stairs was got when walking up them but actually research shows the most benefit is achieved when walking down them with improvement in leg muscle strength, balance, cardiovascular health, bone density and blood sugars. So even if you get the lift up consider walking down.
Dr Harriet Doyle, Senior GP Partner, Tavyside Heatlh Centre
Arranging an appointment at your GP surgery can feel challenging! You may find that you have to wait for the phone to be answered only to discover that the Care Navigators aren’t able to offer you the appointment that you want, and the next available appointment slot may seem like an awfully long time away. When you arrive in the waiting room you may see a sign telling you that you should only discuss one thing with the doctor and make another appointment if you have multiple problems and you only have a 15-minute slot to tell your story.
Many patients feel hurried by this short time frame and it can be tough for the doctor too; in 15 minutes they have to engage with the current problem which may be complex, deal with ongoing conditions like Asthma, Diabetes, offer interventions such as how to stop smoking and listen out for a hidden agenda – the reason you might have come, but haven’t felt able to raise. So it’s no surprise that there are calls for GP appointments to be extended to 15 minutes even though this would mean seeing fewer people per session; GPs in the UK often see 40 patients a day and sometimes more, although many EU countries say 25 a day is a safer workload. In the last five years there has been a 13% increase in face-to-face contacts and a 63% increase in telephone contacts but the increase in workload has not been matched by a transfer in the proportion of funding or staff.
So how can you make the most of your appointment time?
Explain to the receptionist why you have phoned. This may include a bit of information about the condition you would like to discuss with the doctor. They are experienced and able to priorities your request as appropriate, particularly if your symptoms are serious, it may be that another member of staff is better able to deal with your needs. It is important to remember that receptionists work within the parameters set out by the doctors, so it is not always possible for them to be able to give you exactly what you would like but will do their best to facilitate your appointment.
Your GP will start with an open question such as ‘what brings you here today?’ This is an invitation to tell your story. Evidence suggests that if you are allowed to talk uninterrupted for 90 seconds, you will be able to share the key details which will allow your doctor to make a diagnosis. This may be backed up with a few specific questions, an examination and some basic tests. Doctors are trained to listen out for ‘red flags’ that may indicate that you have a serious underlying problem, for example; if you say you’ve had unexplained weight loss or a new breast lump, expect further detailed questioning and urgent referral for investigations and a specialist opinion. Other diagnosis are made by recognising a pattern of typical symptoms that suggest a particular cause and then confirming the diagnosis with examination and tests. Don’t feel you need to be to be too clever. Some people will Google their symptoms, find a diagnosis and then mould their story to fit it but the ‘best historians’ just tell their symptoms as they are. However if there is something specific that you are worried about then it’s fine to ask; ‘I’ve had tingling in my right hand and pain in my neck for the past week since I got back from a cycling holiday’, this may say a trapped nerve to the GP but if you are worried you may have multiple sclerosis, you should say, so this worry can be specifically dealt with. And don’t leave the most important thing until last as it will almost certainly be worthy of more than the minute of time that might be left at the end of the consultation!When it comes to the examination, you need to be prepared to show the body part that you are concerned about. Nail varnish makes it impossible to examine for a possible fungal infection. It is time consuming to remove skinny jeans and high boots in order to have a rash on your calf checked out. It’s understandable for teenage girls with facial acne to wear makeup however this needs to be wiped off before the appointment if severity of the condition is to be assessed appropriately. If you would like a chaperone for your examination then that can easily be accommodated. All GP surgeries offer chaperones, so if you would like someone with you for an intimate examination, you can just ask. Don’t feel you need to apologies; you may feel embarrassed but your GP won’t. The most important thing is to be clear and open about your concerns so they can assessed appropriately. If you prefer to bring someone with you for support or another pair of ears that is fine too. But don’t let them talk over you or interrupt. It is your story.
Bringing additional observations with you can also be helpful. You may have a blood pressure machine at home which have been using on a weekly basis and a record of these results is really useful. Likewise peak flow measurements, weight changes, blood sugars, the date of your last period or a list of allergies can also add valuable information if they relate to the problem you want to discuss. If you think you might have a urine infection, bringing a sample in a sample pot means it can be tested on the spot and a diagnosis and treatment plan offered straight away, with time left over for a medication review and a relaxed chat about your holiday. You’ll be in and out within ten minutes – sometimes that’s all it takes!
One final thing; please be understanding if your doctor is running late. Almost certainly this will be due to something beyond their control; there might have been a medical emergency, or an earlier patient may have been recently bereaved, or been told they have cancer. On those occasions it is important that a bit more time is spent helping them through a life changing moment.
Dr Jo Coldron, GP Partner, Tavyside Health Centre
Blood pressure
As a GP, I must send out so many messages to patients to update their blood pressure (BP) – some days I feel like I’m obsessed with it, but that’s because it’s simultaneously very important to our long term health and usually causes no early identifying symptoms, so unless you’re looking for it, a high blood pressure can go unnoticed for many years.
The reason it’s important, is that a high blood pressure ongoing for months or years, puts extra strain on the body’s systems and is a risk factor for heart attacks, strokes, dementia and kidney disease among other things.
Because high blood pressure can exist for many years without causing any symptoms, even though it’s gradually causing problems in the background, we are asked to try and make sure that we have a blood pressure reading every five years or so in all our patients who are aged over 40. So that may be the only reason we send you a message asking you to ‘update your BP’.
For many patients, we strive to have much more regular BP checks. Patients who have illnesses that already put them at a higher risk of heart attacks, strokes and kidney disease for example diabetes, kidney disease, schizophrenia, previous mini-stroke, rheumatoid arthritis and many others. Patients who are on certain medications, for example, the combined contraceptive pill or HRT and of course anyone who has already been identified as having high or borderline blood pressure whether or not they are on blood pressure medication, should have their BP monitored at least yearly.
What we do with the results, depend on two factors – the result AND the patient. There is no one number that is a definite threshold for saying below this your BP is fine and above this your BP is high and you need medicines. Blood pressure is part of the complex story for each individual patient and only one of the risk factors impacting our long-term health. So, we would be much more likely to want to treat BP with medications in a young diabetic than we would in a fit and healthy 92 year old – even though the numbers may be the same.
However, there are some useful guidelines for when to prompt a review by your GP, if you are checking your own blood pressure at home but are otherwise well.
If your BP is over 180/120 on repeated testing, you should make contact with your GP that day to assess you.
If your BP is between 140-180/90-120 you might have high blood pressure and you should alert your GP so that over a few weeks they can assess you and arrange appropriate blood pressure and blood tests to be able to advise you appropriately.
If your BP is between 120-140/80-90 you may be at higher risk of developing high blood pressure. For these people especially, but for us all, there are lots of things we can do to reduce our blood pressure and long-term risk of disease.
- Decrease the salt in your diet and increase the fibre
- Limit your alcohol to the recommended 14 units per week
- Lose weight if you are overweight
- Increase activity in any way you can but 150 minutes of moderate activity like brisk walking is ideal
- Decreasing caffeine if your intake is high
- And to complete this classic list of things your GP will tell you is important whatever you go to them about – stop smoking. Smoking doesn’t actually cause high blood pressure but hugely increases the risk of arterial disease and therefore raises the risk of significant illness associated with high blood pressure.
There are some great resources on the NHS and the British Heart Foundation websites that contain lots of useful resources and information https://www.nhs.uk/cond…/high-blood-pressure-hypertension/
Dr Jo Coldron, GP Partner, Tavyside Health Centre
I’ve always been a sport enthusiast, although I count watching, not necessarily doing, sport in that wider category. After a brief secondary school foray into the cross country team running wasn’t really something I was either good at or enjoyed, until my 30s. When home and work life becomes increasingly hectic I think the lure of 45 minutes on one’s own outside is a great motivator. With lots of support from family and friends I have gradually increased the distance I run until I did my first marathon on my 40th birthday.
As I get older and creakier though I am starting to get niggling knee pains, classic signs of the start of mild osteoarthritis (OA). It seems natural to wonder if this could be because of my running, and would it mean that I would have to stop something that I’ve come to love. It is very logical to think that continued high impact blows to the knees would cause further damage and pain. As knee OA affects so many of us this is also a discussion played out in various different forms with lots of my patients, so I know that many of you will be interested to hear what the evidence seems to show.
Well, there is controversy – as there always is with lots of studies, done in many different ways, looking at something as complicated as the human body. However many studies fall firmly on the side of running.
There is certainly a significant body of evidence that shows running, for most people, doesn’t harm the knees, and doesn’t cause increased pain – these findings seems to be reproducible and robust. However we can interpret some studies further which seem to show that runners have LESS knee pain than non-runners. Grace Lo et al in 2017 looked at over 2000 people with a mean age of 64 and BMI of 28 (slightly overweight) so very representative of my patients presenting with knee pain. In that study runners were 24% less likely to report knee pain than those who had never run. Interestingly those that didn’t run now but had run for a while at some time in their life reported 18% less knee pain. So it seems as if the positive effects of running could well be long lasting.
So if we’re saying that running doesn’t cause knee osteoarthritis, what does? A study by Dan Lieberman et al showed that knee osteoarthritis has hugely increased in prevalence in the generations born since the Second World War. Factors responsible for this increase seem to be
- Continuous walking on hard paved surfaces
- High heeled shoes
- Inactivity – a hugely significant factor for knee OA and many other diseases
Why is inactivity thought to have such an effect?
- I think we’d all agree that people who are more active tend to have lower body weights and therefore put less load on the knee joints, and this is certainly an important factor.
- Inactivity, for example sitting at a desk all day, at any age, leads to deconditioning of the body. Joints have thinner and more fragile cartilage, and the legs have weaker stabilising muscles, leading to increased risk of injury on any movement of the joint making early onset knee osteoarthritis more likely.
- Exercise and activity also has an anti-inflammatory effect directly within the synovial fluid of the joint. This decreases the inflammation associated with OA of all stages. It is perhaps this ongoing reduction in inflammation, even in a ‘normal’ joint that provides the effect that running seems to have of reducing knee pain. It may also be the reason why our logical thought that high impact sports are bad is incorrect, as it is this high impact exposure that initiates the greatest anti-inflammatory effect. Exercise and activity also has a body wide anti-inflammatory effect so decreasing the risk of other inflammatory related diseases such as diabetes, cardiovascular disease, stroke and vascular dementia. It really is the drug we should all be taking.
So it seems clear that activity and exercise, to the limits of what your body can do, at any stage of knee osteoarthritis – even before you have any symptoms at all – is very useful. And if you can – run! As my grandmother repeatedly tells me at age 94 – “use it or lose it”.
The NHS is always looking for ways to save money where it can to have more available in the pot for essential services. You may have noticed in your interactions with your GP surgeries recently that one of the areas targeted for saving are medicines that are called ‘over the counter’ (OTC) medications. These are medicines that can be prescribed by your doctor, but you could also buy without a prescription from a supermarket or pharmacy, for example, paracetamol, antihistamines, migraine tablets, steroid creams and many more.
It’s estimated that around 569 million pounds are spent by the NHS on prescribing OTC medications. Of course a lot of these medications should continue to be prescribed, for example, long term painkillers for chronic pain like arthritis, or when patients are complex or on many interacting medications. There are lots of situations where prescriptions are still the best and safest way of providing these medications. So the NHS is concentrating the efforts on trying to restrict prescribing for ‘minor’ conditions – things that usually get better on their own or could be treated by the patient alone or with advice from their local pharmacist.
Our pharmacy colleagues are highly trained and experienced professionals who have many roles within the modern NHS, for example, helping patients manage acute minor illnesses, improving patient safety and compliance with their medications and helping GPs manage chronic illness. They are often available for confidential consultations without a wait and at times when GP surgeries are typically less available like evenings, weekends and bank holidays. They can offer medical advice on a huge range of problems like rashes, cystitis, headaches, coughs and colds, constipation, emergency contraception, nappy rash and much more. If they feel you need to see a GP they can certainly advise this, but seeing them first for some of the more common and minor medical complaints could well save you a wait to get started on effective treatment.
Another good source of information on self-limiting and minor ailments is the NHS website (www.nhs.uk). Use the search box to find up to date information leaflets on a huge range of different topics from Acne to Zika Virus which can often answer all your questions and guide you to the best treatment options. When providing information leaflets to my patients this is often the source I use for these.
So if we all worked together to decrease prescriptions for OTC medications what could we accomplish? It is estimated that if GPs wrote less prescriptions for minor illnesses we could save up to 136 million pounds per year! To put this into context, for every one million pounds saved this could fund:
39 more district nurses
66 more drug treatment courses for breast cancer
270 more hip replacements
1000 more drug treatment courses for Alzheimer’s
1040 more cataract operations
I hope you stay well this winter but if you do end up feeling under the weather for whatever reason it may be that you can get appropriate advice and effective treatment quickly and without even needing to see a GP.
Dr Jo Coldron, GP Partner, Tavyside Health Centre
I think that one of the scariest things that can happen to you is to be a bystander when someone suddenly collapses, whether it’s a family member or a stranger. Even as a doctor who has been on emergency response arrest teams at hospital and been involved in the resuscitation of many people it makes the adrenaline pump. Despite how unexpected and terrifying this situation would be just a little bit of knowledge could enable you to save someone’s life.
If someone collapses it’s really important to be able to work out what you need to do now. They might just have tripped and just need you to help them up and on to the bus or they may have had a cardiac arrest and need life saving action immediately.
The way we remember what to do to assess the situation is by thinking Dr ABC
- Danger – look for danger – don’t dash out into the middle of a road to get to someone before making sure you’re not going to get run over. That adrenaline can make you do crazy things sometimes that’s why this step is always first.
- Response – are they responsive to you? Ask loudly if they are OK, perhaps shake them a little.
- Airway – tilt the head up a little to open the airway.
- Breathing – is the chest moving up and down, can you feel air moving in and out of their mouth?
- Circulation – are there any signs of life, any movement at all? Don’t feel that you have to check for a pulse if you’re not sure how to do it, this will just waste time.
If after doing the Dr ABC you assess this collapsed person and they don’t seem to be breathing and they aren’t showing any signs of life you have to assume that they have had a cardiac arrest which means their heart has stopped beating. This person’s chances of survival can be increased by the following things three things, and doing all of these things needs more than one of you – so call for help loudly, or go quickly and make sure you get that support if it’s possible to do so.
Calling the ambulance as soon as possible. The call handlers are wonderful and will help you give them right information but being able to tell them clearly and confidently that the person is not breathing and not responsive will immediately let them know how serious this situation is and get that ambulance there as soon as they can.
Doing basic life support (chest compressions and rescue breaths, CPR). If you haven’t been trained to do basic life support it can seem so confusing and people worry about doing it wrong so end up doing nothing. It is so important to know that doing ANYTHING is better than nothing. One of the biggest barriers is the thought of giving mouth to mouth rescue breaths so unless you feel confident with these just do chest compressions and keep going.
Performing early defibrillation. This is the absolute key to increasing survival. It is so important that many organisations have made defibrillators available on the outsides of buildings like town halls, doctors surgeries, shopping areas, pubs….. When you’re out and about note where these big yellow boxes are because one day you might need them. If the collapsed person isn’t breathing or showing signs of life immediately send someone to go and get a defibrillator and bring it to you as soon as possible. These defibrillators are designed to be used by someone who has never had any training. They talk you through how to put the pads on, tells you when to do CPR and when not to touch the patient and directs you when to deliver a shock. You can trust them and many lives have been saved by someone with absolutely no medical experience performing an early shock with one of these machines.
Practicing a scary event like this makes it much less daunting when it does happen, and makes you much more confident about what to do (and remember doing ANYTHING is better than nothing). The Resuscitation Council UK has produced a way to experience different medical emergencies via 4 interactive scenarios where you make the decisions and save people’s lives. Have a look at these today on https://www.resus.org.uk/apps/lifesaver/
Dr Jo Coldron, GP Partner, Tavyside Health Centre
I love smiling, I do it all the time – to my patients and colleagues, to strangers, with my children, on my own in the car. It is one of the most powerful tools I have to connect with my patients, young and old, and help them feel better in periods of distress and pain. Even in the most harrowing of consultations a smile is essential and can communicate so much which can’t be said in words. We feel the positive effects of smiling every day but how and why is it so good for us?
Smiling is important from the moment we are born. If babies aren’t exposed to smiling their global development is significantly impaired. The very first milestone we check for in the long and complex journey of child development is the smile which develops at 6 weeks – a human being’s very first learned skill.
Studies show that smiles are key to social cohesion and interaction. We are more attracted to smiling faces than stern ones, and this overrides effects of age, gender and race that tend to influence our initial attraction and openness to others. If we smile people see us as more attractive, reliable, relaxed and sincere. Seeing a smiling face activates your orbitofrontal cortex, the region in your brain processing sensory rewards. This suggests that when you view a person smiling, you actually feel that you’re being rewarded.
So seeing others smile makes us feel good, but I know when I smile it makes ME happy. Darwin was one of the first to detail the ‘Facial Feedback Hypothesis’, which described the fact that if you physically express your emotion, it intensifies that emotion i.e. if you feel happy and therefore smile, the action of smiling makes you even happier.
Not only does smiling make you happier it can have very real and measurable effects on your physical health. This is because every time you smile the physical action signals the release of dopamine, endorphins and serotonin. These hormones are related to lowered blood pressure and heart rate, reduced stress and all the health problems that come hand in hand with that, they are natural painkillers and aid relaxation. This explains the strong link between positive happy emotions and frequency of smiling with higher life expectancy overall, quicker recovery from illness and lower risk of diseases such as heart attacks and strokes. It can also moderate the effect of chronic illnesses like arthritis. A study found that social laughter increases your pain threshold, creating a higher pain tolerance.
The fascinating thing is that the body doesn’t seem to know the difference between a real and a ‘fake’ smile – so it seems that you can literally smile yourself to healthiness and happiness.
And if all that hasn’t convinced you smiling is a wonder drug apparently studies have shown that while you are smiling on average you look 3 years younger!!
So smiling can make you feel great but even more marvellously smiling is infectious. The part of your brain that is responsible for your facial expression of smiling when happy or mimicking another person’s smile is located in the cingulate cortex, an unconscious automatic response area. If you beam at someone about 50% will automatically smile back, hence spreading the positive effects of your smile.
We can all benefit from smiling more – a free drug than makes us and those around us healthier and happier, with no side effects, there is no reason not to! Some suggestions of how to get those extra smiles into the day are:
- Smile as soon as you wake up
- Remind yourself in the morning that you’re going to smile more today
- Have a ‘smile buddy’ someone else who is actively trying to smile more, or someone who naturally smiles frequently, and spur each other on
- Seek out happy, positive experiences, like watching a comedy, looking through old photos of happy events, meeting up with good friends
- Create cues to smile (remember a ‘fake’ smile is still beneficial) for example every time you stop at traffic lights, or set a reminder on your phone.
- Indiscriminately smile at strangers – perhaps some will become friends!
I know what makes me healthy and happy, in fact we all do. It basically consists of treating our body well, being with people who we like and love doing things we enjoy. But sometimes it seems so difficult to get that right. I find myself filling spare time with work or finding an excuse to not go out for that run I’d told myself I’d do. However the last 6 months have been something of an epiphany for me.
Some time in summer last year I signed up for a race with my friend Becks. It was way beyond anything I have ever done in my life but with 12 months to go, sitting on a sunny beach, it seemed like a fine idea. As the time got closer, and the event became reality Becks and I started training. Over those months I have learnt how to swim front crawl, discovered cycling on Dartmoor and been impressed and amazed by Becks on a daily basis. I have been supported by family and work colleagues and got to know new and inspirational people. And in the end both Becks and I got a medal for our first (and perhaps not last) Ironman 70.3.
All of this from just signing up for a race. There are many seasoned athletes who enter races all the time of course but for my fellow ‘big event novices’ I have some suggestions about how to approach your first race.
Choosing the event:
It should be personal to you and a significant challenge. Perhaps it would be something linked to a loved one for example the cancer research 5km Race For Life, or St Luke’s Tour de Moor cycle ride. It could be something that involves family generations in one event like the Dartmoor Rescue 11 tors walk or the Abbots Way walk . Perhaps it would be something clearly ridiculous and fantastic that you would never normally do like a 24 hour running event. Or something so extreme it could change your life forever like an ultramarathon across the arctic.
Before the event:
Tell as many people as you can. Getting support and encouragement from your friends and family is invaluable. Once you have told people you’re doing something it makes it a lot harder to back out.
Training for the event:
Make training as social as possible. It’s proven that group exercise is as good for you physically as solo exercise but much better in terms of enjoyment and mental well-being. There were many times I would not have gone out if I hadn’t promised Becks I would, not letting her down was the motivation behind much of my training. Enthuse friends and family to do the event with you, or join a club to train.
During the event:
Enjoy the day. Often these events come with something of a party atmosphere, something you can’t experience normally. Hundreds of people in lycra or fancy dress nervously about to do something exceptional. This might be the start of something that will change your life, or it might be the only time you do this. Whichever it is savour the moment.
Commit to finish and keep moving forward at your own pace. This seems simple but focussing on this can make the seemingly impossible happen. Instead of thinking about all the miles and hills between you and the finish and how hard it is, think about being there. If you can, run, but if you can’t run walk – you are still moving towards the goal and you can do it. Don’t focus on everyone else who suddenly seems to look fitter and stronger and faster than you, you are there, racing your race at your pace. There is always going to be someone looking at you thinking YOU are stronger and fitter and more relaxed than them.
Smile, be kind and say thank you. Most of the events are manned by volunteers and enthusiasts. Their encouragement, help and dedication make everything possible and a large part of the afterglow you get from taking part is due to those fleeting interactions on the course. An ‘Allez’ at a difficult moment on a hill can feel as important as any nutrition plan.
So pick your race, train and have fun!
Links to events mentioned:
Cancer research race for life – https://raceforlife.cancerresearchuk.org/
St Luke’s Tour de Moor – https://www.stlukes-hospice.org.uk/tourdemoor/
Dartmoor rescue 11 Tors walk – https://www.dsrt-tavistock.org.uk/11-tors/
Abbots way walk – https://www.dartmoor.gov.uk/enjoy-dartmoor/events/events-list/dartmoor-events/abbots-way-walk
Hope 24 hour running event – http://hope24.team-hope.co.uk/
Dr Jo Coldron, GP Partner at Tavyside Health Centre
Over the last couple of years there has been a huge increase in people using injectable medications for weight loss treatment. Because of the limited availability on the NHS for people who are not diabetic much of this is privately sourced. There are around half a million users in the UK.
The main medications available are Tirzepatide (the brand name is Mounjaro) and Semaglutide (the brand names are Ozempic and Wegovy).
All these medications are called GLP-1 injections and they work by mimicking a naturally occurring hormone, glucagon-like peptide-1 (GLP-1), to help regulate blood sugar and promote weight loss. They achieve this by causing lots of changes in the body including increasing insulin production, reducing glucose production in the liver, and slowing down food digestion, leading to a feeling of fullness and reduced appetite.
They are very effective weight loss mediations when you are taking them, but on stopping them over a few weeks the effects diminish, appetite returns and most people regain a substantial proportion of the weight lost over the following months unless they have simultaneously managed to make dietary and lifestyle changes.
On the whole the data we have at present indicates these are relatively safe medications. The main side effects are gastric with people feeling sick, vomiting, being constipated or having diarrhoea and experiencing abdominal discomfort and increased flatulence. Other common side effects are tiredness, dizziness and hair loss.
There are some people who should NOT take GLP-1 injections for example people with significant gastrointestinal diseases, anyone who has had pancreatitis before, or anyone who is pregnant and breastfeeding.
There is no little data about the safety of these medications in pregnancy and it is advised that if you are using these injections you should be using an effective form of contraception and continue this for up to 3 months after stopping them.
As a GP with a special interest in women’s health I’m aware there are 2 groups of people who may be using GLP-1 injections and could run into problems:
Women of childbearing age – Mounjaro (but it seems not ozemipic or wegovy) has a significant impact on how well the body can absorb the contraceptive pill – both the combined pill, and the progesterone only pill. This can decrease the effectiveness of the pill and put women at risk of unplanned pregnancy. If you are using pills for contraception you should be using extra precautions for a month after you start Mounjaro AND for a month after any dose increase. Contraceptives like implants or coils are not affected and are safe to use. If you are taking the pill and do not want to use barrier contraception perhaps consider changing to a more effective contraceptive method before starting the injections. This is a very good information leaflet that covers lots of issues to do with GLP-1 injections and contraceptive pills: https://www.fsrh.org/Common/Uploaded%20files/documents/Patient-information-GLP-1-agonists-and-contraception.pdf
Postmenopausal women on HRT – it’s thought that all GLP-1 injections, but likely especially Mounjaro, can impact the absorption of HRT taken by mouth. So for those taking oral oestrogen the injections could cause your menopausal symptoms to increase. More concerning is if you are using an oestrogen through the skin via a patch, spray or gel AND oral micronised progesterone (utrogestan) tablets. If you have the normal amount of oestrogen but too little progesterone the lining of the womb is not adequately protected and this can cause bleeding and increase the risk of endometrial cancer. If you are on HRT with oral progesterone, before you start the GLP-1 injections, please discuss with your GP the options of either increasing your oral progesterone or change to a progesterone mixed in to the patch or via a coil. If you do have increasing or unexpected bleeding on your HRT preparation please discuss with your GP.
Dr Jo Coldron, GP Partner, Tavyside Health Centre
It’s well known that we are all recommended to do at least 150 minutes of moderate intensity cardiovascular exercise during the week – this is often promoted as 5 x 30 min sessions. Less publicised are the department of health’s recommendations that we should all be incorporating muscle strengthening activities on 2 days per week, and in addition for older adults (over 65) balance improving activities on 2 days per week.
Although there are many ways to achieve improvements in muscle strength and balance, in this article I’m going to focus on 3 activities which have been shown in studies to improve physical health specifically through muscle and balance conditioning.
Tai Chi
Tai Chi is an ancient Chinese martial art, but it is now mainly practiced for it’s health benefits rather than combat. There are a number of different styles but all are characterised by slow, graceful, continuous movements that are gentle on the joints and muscles and are linked to controlled breathing and focus of the mind. Although Tai Chi is undoubtedly good for us at any age, most studies have focussed on the benefits for older people where it’s been shown to improve balance and muscle strength, thereby reducing falls. There are also studies that show it decreases stress. You are never too old to do Tai Chi and it is recommended by the NHS falls clinic to anyone who may be at risk. If you are older and more frail it’s important you join a group with an experienced teacher who can adapt exercises for your fitness and experience level.
Yoga
Yoga is an ancient Indian practice that has been adapted to our western palates as a way of improving both physical and mental health. Although all forms of yoga focus on moving between different postures and incorporating breathing there are a huge variety of forms of practice. Some are very calm and meditative, focussing primarily on the mental health benefits. Some are very physical and dynamic putting the emphasis more on muscle conditioning and flexibility. Yoga has been shown to increase flexibility and strength which can reduce falls and help reduce chronic joint pain. It has also been shown to mitigate stress and low mood, and lower blood pressure. Again, anyone can do yoga – but choosing a class aimed at your level of fitness is important. There is even ‘chair yoga’ for the very frail.
Pilates
Pilates is the only one of our 3 disciplines that isn’t ancient. It was developed in Germany at the start of the 20th century and was designed to improve strength and flexibility through controlled movements incorporating the whole body. It puts emphasis on developing a strong core, balance and stability. There is less formal evidence for the efficacy of pilates but because it’s main principles and focus are similar to yoga and Tai Chi – low impact, muscle conditioning, improvement of balance, focus and breathing – it is thought it may have some similar benefits and is recommended by the NHS. Due to the focus on core muscle strength (back, abdominal and pelvic floor muscle groups) it is often suggested as a way of tackling the epidemic of back pain which is exacerbated by our more modern sedentary lifestyles which lead to a deconditioned core.
All these forms of exercise are accessible to all, no matter your fitness, experience or age. Just in our local area we have groups for mums and babies, over 65s, for men only, for women only, for children, for athletes, there are outside classes, group classes, one to one sessions…… the list goes on. A quick internet search will reveal the wealth of options available.
For a basic introduction to each of the disciplines in this article, and the health benefits provided please see these NHS information sheets.
https://www.nhs.uk/live-well/exercise/guide-to-tai-chi/